18. Urogynecology Flashcards
Identify parts
Identify
Rectocele
A rectocele is a herniation (bulge) of the front wall of the rectum into the back wall of the vagina.
Identify
Cystocele
A cystocele is when the wall between the bladder and the vagina weakens. This can cause the bladder to drop or sag into the vagina.
Identify
Uterine Prolapse
Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the vagina.
Identify
Enterocele
Enterocele is the descending of the small intestine into the lower pelvic cavity.
Define: Pelvic Relaxation/Prolapse (1)
Protrusion of pelvic organs into or out of the vagina
Describe etiology of prolapse (1)
relaxation, weakness, or defect in the cardinal and uterosacral ligaments which normally maintain the uterus in an anteflexed position and prevent it from descending through the urogenital diaphragm (i.e. levator ani muscles)
Prolapse is related to what? (8)
- vaginal childbirth
- aging
- decreased estrogen (post-menopause)
- following pelvic surgery
- increased intra-abdominal pressure (obesity, chronic cough, constipation, ascites, heavy lifting)
- congenital (rarely)
- ethnicity (Caucasian women > Asian or African women)
- collagen disorders
Describe general conservative treatment of prolapse (3)
(for pelvic relaxation/prolapse and urinary incontinence)
- Kegel exercises
- local vaginal estrogen therapy
- vaginal pessary (intravaginal suspension disc)
Describe: Grading of Pelvic Organ Prolapse (6)
- 0 = no descent during straining
- 1 = distal portion of prolapse >1 cm above level of hymen
- 2 = distal portion of prolapse ≤ 1 cm above or below level of hymen
- 3 = distal portion of prolapse > 1cm below level of hymen but without complete vaginal eversion
- 4 = complete eversion of total length of lower genital tract
- Procidentia : failure of genital supports and complete protrusion of uterus through the vagina
Define: Cystocele (1)
protrusion of bladder into the anterior vaginal wall
Describe clinical features: Cystocele (3)
- Frequency, urgency, nocturia
- Stress incontinence
- Incomplete bladder emptying ± associated increased incidence of UTIs (may lead to renal impairment)
Describe tx: Cystocele (3)
- General conservative tx
- Anterior colporrhaphy (“anterior repair”)
- Consider additional/alternative surgical procedure if documented urinary stress incontinence
Define: Enterocele (1)
prolapse of small bowel in upper posterior vaginal wall
Describe tx: Enterocele (2)
- Similar to hernia repair
- Contents reduced, neck of peritoneal sac ligated, uterosacral ligaments, and levator ani muscles approximated
Define: Rectocele (1)
protrusion of rectum into posterior vaginal wall)
Describe clinical features: Rectocele (2)
- Straining/digitation to evacuate stool
- Constipation
Describe tx: Rectocele (3)
- General conservative tx
- Also laxatives and stool softeners
- Posterior colporrhaphy (“posterior repair”), plication of endopelvic fascia and perineal muscles approximated in midline to support rectum and perineum (can result in dyspareunia)
Define: Uterine Prolapse (1)
protrusion of cervix and uterus into vagina
Describe clinical features: Uterine Prolapse (7)
- Groin/back pain (stretching of uterosacral ligaments)
- Feeling of heaviness/pressure in the pelvis
- Worse with standing, lifting
- Worse at the end of the day
- Relieved by lying down
- Ulceration/bleeding (particularly if hypoestrogenic)
- ± urinary incontinence
Describe tx: Uterine Prolapse (3)
- General conservative treatment
- Vaginal hysterectomy ± surgical prevention of vault prolapse
- Consider additional surgical procedures if urinary incontinence, cystocele, rectocele, and/or enterocele are present
Define: Vault Prolapse (1)
protrusion of apex of vaginal vault into vagina, post- hysterectomy
Describe tx: Vault Prolapse (1)
- General conservative tx
- Sacralcolpopexy (vaginal vault suspension), sacrospinous fixation, or uterosacral ligament suspension
The only true hernia of the pelvis is what? (1)
an ENTEROCELE because peritoneum herniates with the small bowel
Define: Stress incontinence (1)
involuntary loss of urine with increased intra-abdominal pressure (cough, laugh, sneeze, walk, run)
Name risk factors for stress incontinence in women (9)
- age
- obesity
- parity
- vaginal delivery
- pelvic prolapse
- pelvic surgery
- hypoestrogenicstate (post-menopause)
- smoking
- neurological/pulmonary disease
Describe tx: Stress incontinence (2)
- see Prolapse, GY36
- surgical
- tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-Marchetti-Krantz procedures)
Define: Urge incontinence (3)
- urine loss associated with an abrupt, sudden urge to void
- “overactive bladder”
- diagnosed based on symptoms
Describe etiology: Urge incontinence (2)
- idiopathic (90%)
- detrusor muscle overactivity (“detrusor instability”)
Name associated symptoms: Urge incontinence (4)
- frequency
- urgency
- nocturia
- leakage
Describe tx : Urge incontinence (3)
- behaviour modification (reduce caffeine/liquid, smoking cessation, regular voiding schedule)
- Kegel exercises
- medications
- anticholinergics: oxybutinin (Ditropan®), tolterodine (Detrol®), solifenacin (VESIcare®)
- tricyclic antidepressants: imipramine
Name neurological causes of urge incontinence to rule out (3)
- MS
- Herniated disc
- DM
